Proximal Aspect Research Articles

ASSESSMENT OF A NOVEL DYNAMIC HIGH-STRENGTH SUTURE TAPE IN DISTAL TRICEPS TENDON REPAIR: A BIOMECHANICAL COMPARATIVE STUDY

IntroductionDistal triceps tendon rupture is related to high complication rates with up to 25% failures. Elbow stiffness is another severe complication, as the traditional approach considers prolonged immobilization to ensure tendon healing. Recently a dynamic high-strength suture tape was designed, implementing a silicone-infused core for braid shortening and preventing repair elongation during mobilization, thus maintaining constant tissue approximation. The aim of this study was to biomechanically compare the novel dynamic tape versus a conventional high-strength suture tape in a human cadaveric distal triceps tendon rupture repair model.MethodSixteen paired arms from eight donors were used. Distal triceps tendon rupture tenotomies and repairs were performed via the crossed transosseous locking Krackow stitch technique for anatomic footprint repair using either conventional suture tape (ST) or novel dynamic tape (DT). A postoperative protocol mimicking intense early rehabilitation was simulated, by a 9-day, 300-cycle daily mobilization under 120N pulling force followed by a final destructive test.ResultSignificant differences were identified between the groups regarding the temporal progression of the displacement in the distal, intermediate, and proximal tendon aspects, p<0.001. DT demonstrated significantly less displacement compared to ST (4.6±1.2mm versus 7.8±2.1mm) and higher load to failure (637±113N versus 341±230N), p≤0.037. DT retracted 0.95±1.95mm after each 24-hour rest period and withstood the whole cyclic loading sequence without failure. In contrast, ST failed early in three specimens.ConclusionFrom a biomechanical perspective, DT revealed lower tendon displacement and greater resistance in load to failure over ST during simulated daily mobilization, suggesting its potential for earlier elbow mobilization and prevention of postoperative elbow stiffness.

Exploring young consumer's understanding of local food through proximity and social representations

The ever-changing nature of consumers' understanding of local food highlights the need for in-depth research. This study explores how Gen-Z consumers define, perceive and experience local food. Through the analysis, we extend the existing conceptualization of local food by differentiating three aspects of proximity: geographical, value, and relational proximity. We contribute novel insights into the differentiation of proximity to the established understanding for this specific consumer group. Methodologically, we use a free association game played with Gen-Z consumers in Hungary. Theoretical frameworks, including social representation, central core and proximity theories, are used to uncover implicit knowledge about local food. The results reveal a consumer understanding that associates health, freshness, taste, quality and trustworthiness as the central core of the local food concept. Surprisingly, value and relational proximity gain importance, while geographical proximity takes a peripheral role. This study facilitates a re-evaluation of the local food concept in light of evolving consumer understanding, while also establishing a link between proximity theories and social representation theory. The findings provide practical implications that distinguish different aspects of proximity that are relevant to farmers and policy makers in light of evolving consumer understandings.

PRC with Double Interposition Arthroplasty for Failed Partial Wrist Arthrodesis

Abstract Background In patients with lunate fossa and proximal capitate degeneration, or failed scaphoid excision and partial wrist arthrodesis, double allograft interposition arthroplasty may allow patients to maintain wrist motion and improve pain. Description of Technique Following dorsal exposure of the carpus, a completion proximal row carpectomy is performed. Suture anchors are placed evenly along the perimeter of the distal radius and used to secure a precut sheet of allograft. Additional suture anchors are placed at the proximal aspect of the distal carpal row, securing a second piece of allograft to the proximal capitate and hamate. Patients, Methods, and Results We present the case of a female with osteogenesis imperfecta who failed prior partial wrist fusion for treatment of scapholunate advanced collapse. She declined wrist arthrodesis and was not a candidate for total wrist arthroplasty. Proximal row carpectomy with double interposition arthroplasty provided resolution of her pain and preserved her wrist range of motion. Conclusions Double interposition arthroplasty may provide reliable pain relief and wrist range of motion for patients with advanced wrist arthritis in whom traditional salvage procedures are contraindicated or have failed. Use of this technique offers benefits that may minimize complications and improve longevity compared with previously described allograft interposition techniques.

056. Impacted CBD Stones in Ampula Vater Evacuated by Transduodenal Approach in A 48-year-old Patient at Prof. Dr. IGNG Ngoerah Hospital in 2024

Background: Cholecystolithiasis and choledocholithiasis are common biliary disorders that can lead to significant complications if left untreated. Among these complications, the formation of impacted CBD stones, particularly at the Ampulla of Vater, poses a unique clinical challenge. The Ampulla of Vater is the anatomical site where the common bile duct (CBD) and pancreatic duct converge, and its obstruction can lead to biliary colic, cholangitis, or pancreatitis. Urgent stone removal is critical for improving the patient’s condition. Case: A 48-year-old male patient presents to the emergency department with right upper abdominal pain since 10 days ago accompanied with icteric sclera since 10 days ago. There was nausea and vomiting when eating high-fat foods. The stools were brownish in color, the urine color was similar to tea color. The patient regularly takes UDCA 3 x 250 mg IO, simvastatin 1 x 20mg IO, curcuma 3 x1 tab IO, lansoprazole 2 x 30mg IO. Physical examination showed icteric eyes, jaundice, liver enlargement 2 fingers below costae arch with positive Murphy's sign. Complete blood examination showed leukocytosis, decreased hemoglobin, hypokalemia, as well as increased direct bilirubin, total bilirubin, and indirect bilirubin. BOF result showed sentinel loop on the right umbilical region suspected inflammatory process. MRI impression of choledocholithiasis causing dilatation of EHBD and IHBD proximal aspect without signs of cholangitis, hepatomegaly, simple cyst of left kidney (Bosniak I). Abdominal ultrasound with the conclusion of cholecystitis with dilatation and thickening of the ductus cysticus wall suspicious of inflammation, dilatation of the right and left IHBD, common hepatic duct, to the proximal common biliary duct, the presence of distal obstruction cannot be evaluated because it is covered by intestinal shadows, mild prostatic hypertrophy accompanied by prostate calcification. After Cholecystectomy and Explore CBD transduodenal, the patient was placed with thoracic drain with good outcome. Conclusion: The transduodenal approach to evacuating impacted CBD stones at the Ampulla of Vater is a valuable technique that can yield excellent outcomes in select cases. This case report underscores the importance of a tailored approach based on individual patient anatomy and stone characteristics.

Portfolio location-related decisions: do proximities matter?

PurposeThis paper aims to examine the relationships between how family owners perceive different aspects of proximity to their territory of origin and the location-related decisions of family business portfolios.Design/methodology/approachBy using the data collected from 112 family business portfolios (FBP), the authors carry out an empirical analysis to test the proposed hypotheses. The results are robust across a battery of robustness analyses performed by the authors.FindingsThe analysis reveals a heterogeneous relationship between the different dimensions of proximity and the maintenance and location of portfolio business units. Specifically, we reveal that entrepreneurial families’ social and institutional proximities to their founding territory have a positive influence on their decisions related to investing and maintaining their business portfolio.Originality/valueThese findings open the black box of how business decisions are affected by how business owners perceive their contexts, providing new insights into how corporate decisions in understudied business organisations, business groups, are shaped by the ownership’s proximity to territories.

Unilateral and Bilateral Axillary Arches in Male and Female Cadavers

Among sixteen donors (32 axillae) dissected in our gross anatomy lab, axillary arch was incidentally observed in three cases (five axillae). In three cases, the axillary arch was observed in five axillae-bilateral in one male and one female donor, and unilateral in one male donor. In all the three cases, the five arches consisted of muscular and connective tissue (aponeurotic/tendinous) parts. The muscular parts originated as slips from the lateral borders of the latissimus dorsi muscles and their connective tissue parts ascended and crossed anterior to the axillary neurovascular bundles to attach to various non-osseus structures on the proximal aspects of the arms. This created a canal dorsal to the axillary arch (designated here as axillobrachial canal or ABC) through which the axillary neurovascular bundles ran to enter the proximal aspect of the arms. The presence of such variant fibromuscular slip can be a cause of neurovascular compression syndrome of the upper limb and may complicate surgical procedures in the axillary region. Therefore, it should be considered in the differential diagnosis of neurovascular compression syndromes of the upper limb and axillary mass to avoid misdiagnosis and unintended damage or injury causing complications.

Does intramedullary K-wire buried under the skin justify the treatment for both-bone forearm fracture in children? : A descriptive analytical study

Introduction: Surgical treatment including intramedullary K wire fixation is desirable for unstable pediatric both bone fracture to avoid angulation, rotational deformity and refracture ensuring optimal functional outcomes. However, it is debatable to leave free end of K wire exposed or to bury underneath the skin. The aim of the study is to assess the functional outcomes and complications after intramedullary K wire buried under the skin for pediatric both bone fracture. Method: This is a prospective analytical study performed from 15 August 2021 to 15 February 2023. This study included unstable closed diaphyseal forearm facture in children aged between 5 and 13 years treated with intramedullary K wires which were buried inside the skin. Study variables included demographical profiles, fracture pattern, time for surgical intervention, Modified Flynn et al criteria, time to unite the fracture and any associated complications). Results: Mean age of the patient in our study was 8.70±2.17 years. Average time required to unite the fracture was 3.15±0.62 months. Thirty-Four (97.2%) patients had excellent outcomes; one (2.8%) patient had good functional outcomes based on Modified Flynn et al criteria. Nine (25.7%) patients had bursa formation at proximal aspect of ulnar K wire while one patient (2.8%) had superficial infection at olecranon site. Conclusion: Intramedullary K wire for pediatric diaphyseal both bone fractures is excellent surgical technique. Even though controversy exist between exposed K wires and those buried underneath the skin, buried K wires have reasonable advantages and less side effects in terms of infection and overall functional outcomes. Keywords: Both bone; Bury; Forearm fracture; Functional outcomes; Intramedullary K wire

An Explorative Anatomical Study on Inter-Individual Variation of the Tibial Nerve and Landmarks for Perineural Anesthesia in Horses.

Perineural anesthesia of the tibial nerve can be performed ultrasound-guided or blindly, with the latter still being commonly used in equine practice due to practical constraints, despite its lower accuracy and hence, common failure to achieve desensitization. This may be associated with anatomical variations or inadequate landmarks for injection. To examine the course of the tibial nerve, document potential anatomical variations, and determine optimal landmarks for perineural injection, dissection was conducted along the medial aspect of the tibia in 10 paired cadaver hindlimbs. No anatomical variations of the tibial nerve were observed. Mean tibial nerve thickness was 6 ± 1 mm. The junction with the plantar nerves was located at a maximum of 85 mm and the junction with the medial cutaneous branch was at a maximum of 150 mm proximal to the proximal aspect of the calcaneal tubercle. The mean distance of the tibial nerve to the cranial border of the superficial digital flexor was 11 ± 6 mm. In conclusion, problems with perineural anesthesia of the tibial nerve cannot simply be attributed to anatomical variations. The thickness of the nerve and the amount of perineural tissue may present specific challenges for achieving adequate desensitization. Our results support the generally recommended site for tibial nerve perineural injection at 100 mm proximal to the calcaneal tubercle and 11 mm cranial to the superficial digital flexor.

Blood Flow Restriction Exercise as a Novel Conservative Standard in Patients with Knee Osteoarthritis—A Narrative Review

Knee osteoarthritis is a prevalent joint disease affecting millions of individuals globally. While total knee arthroplasty is an effective treatment for advanced stages of KOA, it may not be suitable for earlier stages or younger patients. Supervised exercise therapy has proven to be the first-line treatment of preference in tackling pain and disability caused by KOA. However, the high intensities required to induce positive muscle adaptations are not indicated in this population, as this is often accompanied by pain, discomfort, and frustration, leaving low-load resistance training as the only feasible method of treatment. Recently, the use of blood flow restriction training has begun to emerge as a substitute for high-load resistance training. With BFRT, a cuff is applied around the proximal aspect of the affected limb, causing partial arterial and full venous occlusion, thereby inducing localized hypoxia and the accumulation of metabolites, mimicking the effects of high-load resistance training, albeit with low loads. Consequently, BFRT might offer a suitable and more effective alternative for KOA patients who are not (yet) eligible for TKA compared to traditional exercise therapy. This review aims to summarize the current evidence as regards the application of Blood Flow Restriction in exercise therapy for knee osteoarthritis patients, with particular consideration of the underlying mechanisms and its safety, as well as general guidelines for practical implementation in clinical practice. In doing so, this narrative review aims to create a framework for translating from theory into practice.

Poster 257: Assessing the Likelihood of Symptomatic Patellar Instability via the Two-Image Lateral Trochlear Inclination Angle as a Measurement of Trochlear Dysplasia

Objectives: Trochlear dysplasia is the most common anatomic risk factor for patellar instability (PI) and it is present in roughly 90% of patients with recurrent PI. Qualitative descriptions/categorizations of dysplasia include the Dejour and Oswestry-Bristol classifications. Quantitative measurements include the sulcus angle and the lateral trochlear inclination angle (LTI). The LTI has shown utility given that it is a numeric representation of dysplasia at the most proximal aspect of the trochlea where dysplasia is most severe. Recently, the two-image LTI has been described as a more accurate and reliable method to quantitate dysplasia compared to the original one-image LTI with high inter and intrarater reliability. However, since the advent of the two-image LTI, no analysis has been done to determine the likelihood of developing (PI) once the LTI reaches a certain value. A prior analysis of the single image LTI showed a value of 11° as a threshold value between patients with and without PI. The purpose of this study is to determine a two-image LTI threshold value at or below which a patient is likely to develop recurrent PI. Methods: Ninety-nine patients with PI and 91 age and sex matched control patients were identified. All patients had available magnetic resonance imaging (MRI) and any patients with unreadable imaging, questionable diagnosis or neuromuscular or arthritic conditions were excluded. Trochlear dysplasia was measured via the two-image LTI (Figure 1). In the study group, any negative LTI values (patients with dysplasia so severe that the trochlea is convex), were excluded from analysis. This left 64 study patients. Means and standard deviations were calculated, and an independent t-test determined significant differences between groups. A receiver-operating characteristic (ROC) curve was plotted to determine the area under the curve (AUC) and a threshold value was determined to best discriminate between study and control patients. Results: The mean two-image LTI in the study group was 9.4 ± 5.2 and 17.3 ± 6.77 in the control group (p < 0.001). Intrarater reliability of 15 randomly selected study patients and 15 randomly selected control patients was excellent (Intraclass Correlation Coefficient: 0.963, 0.924-0.982). ROC AUC was 0.825 (95% CI: 0.758-0.891) as depicted in Figure 2. A threshold value of 14.5° (Table 1) was chosen as the best demarcating value between controls and PI patients with a sensitivity of 0.828 (53/64), specificity of .769 (70/91), and an accuracy of .793 (123/155). Conclusions: In comparison to the single image LTI, the two image LTI had a higher threshold value in discriminating between patients with and without PI (11° vs 14.5°). This is very likely due to the difference in measurement techniques. This information is valuable for risk stratification of patients with PI as one would expect patients with an LTI below 14.5° to have recurrent PI and those patients with a single dislocation with an LTI higher than 14.5° to be more likely to stabilize with conservative management. Given the reliability and representative nature of the two image LTI in assessing trochlear dysplasia, symptomatic trochlear dysplasia (that which results in patellar instability) can be defined for most people as dysplasia with a two image LTI £ 14.5°. [Figure: see text]

Somatic and autonomic nerve density and distribution within the clitoris: an immunohistochemical study in adult female cadavers.

Knowledge of clitoral neuroanatomy is critical to vulvar surgery. We sought to characterize the density and distribution of autonomic and somatic nerves supplying the clitoris. Pelvic tissue harvested from female cadavers was sectioned axially at three anatomic levels: the proximal aspect of the clitoral body (CB), the distal CB, and the glans. The CB, glans, and the surrounding connective tissue (dorsal, lateral, and ventral) were outlined microscopically. An area containing large nerve bundles dorsal to the CB, referred to as the dorsal nerve subregion, was analyzed separately. Double-immunofluorescent staining for beta III tubulin (βIIIT), a global axonal marker, and myelin basic protein (MBP), a myelinated nerve marker, was performed. Threshold-based automatic image-segmentation distinguished stained areas. Autonomic and somatic density were calculated as percentage of tissue stained with βIIIT alone, and βIIIT and MBP respectively. Comparisons were made using nonparametric Friedman tests. Seven cadavers, aged 22-81, were examined. Somatic (mean 4.42%, SD ± 1.97) and autonomic (2.14% ± 2.42) nerve density was highest in the dorsal nerve subregion and dorsal region at the distal CB level. Compared with the CB, somatic density was higher in proximal (0.05% ± 0.03 vs 1.27% ± 0.69, p = 0.03) and distal (0.29% ± 0.25 vs 1.09% ± 0.41, p = 0.05) dorsal regions. Somatic density was greater in the glans than in the surrounding lateral (0.78% ± 0.47 vs 0.43% ± 0.23, p = 0.03) and ventral (0.78% ± 0.47 vs 0.52% ± 0.2, p = 0.03) regions. Autonomic density was greater than somatic in all areas, except for the dorsal nerve subregion. Somatic and autonomic nerve density were greatest in a well-defined region dorsal to the CB. Surgical preservation of this region is critical for maintaining nerve supply to the clitoris.

Computed tomographic evaluation of the proximity of needles placed for perineural anesthesia of the palmar digital nerves to synovial structures in the foot: an ex vivo study.

Potential synovial penetration following palmar digital nerve blocks has not been investigated. To evaluate the proximity of needles placed for palmar digital nerve blocks to nearby synovial structures using computed tomography (CT). Descriptive observational study. In 18 cadaver forelimbs, sequential injection of the navicular bursa (NB), distal interphalangeal joint (DIPJ) and digital flexor tendon sheath (DFTS) was performed using 3, 5 and 10 mL diluted radiodense contrast medium, respectively. After each synovial injection, 25 gage needles were placed over the palmar digital nerves at the proximal aspect of the ungular cartilages (distal injections) and 1 cm further proximally (proximal injections), and CT examination was performed. Subsequently, needles were removed, and the synovial structures further distended with the same volume as for the first injection. Perineural needle placement and image acquisition were repeated. The distance between the needle tip and adjacent synovial structures was measured (mm) in reconstructed images. Results were analyzed in separate general linear mixed models, to determine the effect of needle position and synovial distension on the distance from the tip of the needle to the NB, DFTS and DIPJ. Synovial penetration was confirmed following 12/420 (3%) needle placements (NB n = 5, 1 after proximal and 4 after distal injections; DIPJ n = 2, DFTS n = 2, NB or DIPJ n = 3, all after distal injections). The mean distance from the needle tip to the NB and DIPJ was significantly smaller after the second distension (NB: p = 0.025; DIPJ: p < 0.001) and with the distal needle placements (NB: p < 0.001; DIPJ: p < 0.001). For the DFTS, the distance from the needle tip was significantly smaller with the proximal needle placements (p = 0.001). Ex-vivo study. There is a small risk of synovial penetration when performing palmar digital nerve blocks, especially when distension of adjacent synovial structures is present.

Blood Flow Restriction Therapy After Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament reconstruction (ACLR) rehabilitation necessitates restoration of quadriceps strength to minimize reinjury and optimize return to sport (RTS). Patients recovering from ACLR are limited by pain and activity restrictions, resulting in quadriceps muscle atrophy. Blood flow restriction (BFR) therapy involves performing exercises while a specialized blood pressure cuff is applied to the proximal aspect of the operative extremity and inflated to 40% to 90% of the arterial occlusion pressure, as determined using Doppler ultrasonography. BFR is theorized to induce an anaerobic environment and metabolic stress during exercise, promoting muscle hypertrophy and strength gains. Although the physiological mechanism has not been fully elucidated, it is theorized that BFR combined with low-load resistance training could yield muscle adaptations comparable to those of high-load resistance training. For ACLR patients with pain and restrictions precluding high-intensity strength training, incorporation of BFR into postoperative rehabilitation protocols could help mitigate quadriceps weakness and promote RTS. Randomized controlled trials report a prolonged, dose-dependent relation between BFR use and quadriceps and hamstring strength gains, improved bone and muscle mass, and earlier RTS, whereas other studies report no significant difference in quadriceps size, strength, or patient satisfaction compared with controls. Furthermore, although generally considered safe, there are rare reports of associated adverse events such as rhabdomyolysis, and BFR should be avoided in patients with a history of thromboembolic disease or peripheral vasculopathy. The literature examining BFR after ACLR is heterogeneous; lacks standardization; and contains broad variation in reported cuff pressures, as well as timing and duration of BFR use, among protocols. Although the use of BFR after ACLR shows promise, further study is necessary to elucidate the efficacy, safety, and optimal protocols.

Analysis of Proximate, Functional, and Mineral Composition in Processed Black Rice (&lt;i&gt;Oryza sativa&lt;/i&gt; L. &lt;i&gt;indica&lt;/i&gt;) Flours: A Comparative Exploration

Black rice is utilised to make successful nutraceutical food products because of its high nutrient content. This study sought to determine the proximate compositions, functional compositions, and mineral compositions of processed black rice flour based on different processing methods (Raw, Soaked, and Roasted). The analytical procedures for the processed flours were designed using the standard methodology. The proximate analysis of processed black rice flour revealed a differentiation at (p&lt;0.01) in every parameter except the moisture content of raw and soaked flour. The functional properties of processed black rice flour range from 1.0 to 1.17 g/g for water absorption capacity, 2.21 to 2.43 g/g for oil absorption, and 1.8 to 2.2% for foaming capacity, with raw, soaking, and roasted black rice flour viscosities being 986.0 cP, 997.0 cP, and 951.0 cP, respectively. Bulk density ranged from 1.77 to 1.82 g/cm3. Compared to other processed flours, raw black rice flour greatly showed increased oil absorption and foaming capacity, whereas soaked black rice flour dramatically increased viscosity and bulk density. Raw black rice flour exhibited the highest composition of minerals (phosphorus, potassium, calcium, magnesium and iron) followed by soaked and roasted flours (p&lt;0.01). The roasted black rice flour contained the highest levels of sodium. The investigation's findings demonstrated that raw black rice flour outperformed other processed black rice flour in terms of several proximate, functional, and mineral aspects, proving to be appropriate for the creation of a range of novel food products with positive health effects.

Bailout Distal Internal Carotid Artery Stenting after Carotid Endarterectomy: Indications, Technique, and Outcomes

Distal internal carotid artery (ICA) stenting may be employed as a bailout maneuver when an inadequate end point or clamp injury is encountered at the time of carotid endarterectomy (CEA) in a surgically inaccessible region of the distal ICA. We sought to characterize the indications, technique, and outcomes for this infrequently encountered clinical scenario. We performed a retrospective review of all patients who underwent distal ICA stenting at the time of CEA at our institution between September 2008 and July 2022. Procedural details and postoperative follow-up were reviewed for each patient. Six patients were identified during the study period. All were male with an age range of 63 to 82years. Five underwent carotid revascularization for asymptomatic carotid artery stenosis, and one patient was treated for amaurosis fugax. Three patients were on dual antiplatelet therapy preoperatively, whereas 2 were on aspirin monotherapy, and one was on aspirin and low-dose rivaroxaban. Five patients underwent CEA with patch angioplasty, and one underwent eversion CEA. The indication for stenting was distal ICA dissection due to clamp or shunt injury in 2 patients and an inadequate distal ICA end point in 4 patients. In all cases, access for stenting was obtained under direct visualization within the common carotid artery, and a standard carotid stent was deployed with its proximal aspect landing within the endarterectomized site. Embolic protection was typically achieved via proximal common carotid artery and external carotid artery clamping for flow arrest with aspiration of debris before restoration of antegrade flow. There was 100% technical success. Postoperatively, 2 patients were found to have a cranial nerve injury, likely occurring due to the need for high ICA exposure. Median length of stay was 2days (range 1-7days) with no instances of perioperative stroke or myocardial infarction. All patients were discharged on dual antiplatelet therapy with no further occurrence of stroke, carotid restenosis, or reintervention through a median follow-up of 17months. Distal ICA stenting is a useful adjunct in the setting of CEA complicated by inadequate end point or vessel dissection in a surgically inaccessible region of the ICA and can minimize the need for high-risk extensive distal dissection of the ICA in this situation.

Using infrared thermography to determine changes in teat skin surface temperature after machine milking in dairy cows

Mastitis is among the costliest diseases affecting dairy cows, partly due to the resulting permanent reduction in the quantity and quality of milk produced. Most mastitis cases involve pathogenic organisms entering the cow's mammary gland through the teat canal. The teat has natural defenses against these pathogens that can be disrupted during milk harvesting. These disruptions of the teat's circulatory system and tissue integrity can predispose them to mastitis. Traditionally, machine milking–induced changes in teat blood circulation and tissue integrity have been assessed by means of manual evaluation and ultrasonography. Infrared thermography has previously been shown to produce precise and consistent measurements of skin surface temperatures (SST) on cows' hind teats. Our objective was to describe the variability in the teat SST following machine milking. Describing the variability in teat SST before and after milking could be useful to guide further studies to elucidate the physiology of the effects of milking on teat defense mechanisms. In this observational study, thermographic images of both hind teats from 140 cows immediately pre- and postmachine milking were analyzed. The average SST were subsequently determined at the proximal, middle, and distal aspects of each hind teat using image analysis software. The LSM (95% CI) from general linear mixed models of the pre- and postmilking SST, respectively, were 33.6 (33.5–33.8)°C and 35.4 (35.3–35.5)°C at the proximal aspect, 33.2 (33.1–33.4)°C and 35.2 (35.1–35.3)°C at the middle aspect, and 32.3 (32.1–32.5)°C and 34.0 (33.9–34.1)°C at the distal aspect. The observed increase in SST from pre- to postmilking SST at all 3 aspects of the teat suggest that some of the variability in the SST can be attributed to the milking event. Future research is warranted to investigate the biological relevance of SST changes during machine milking and any potential change in teat defense mechanisms, risk of mastitis, or other pathologies.

Anterior Cruciate Ligament Reconstruction: 3-Incision Technique With Allograft Quad Tendon ACL Reconstruction

Background: Anterior cruciate ligament (ACL) ruptures are becoming more common in younger and older athletes. Approximately 250,000 ACL injuries occur each year, requiring the need for an effective and reproducible surgical technique. Indications: The 3-incision outside-in technique utilizes the donor quadriceps tendon, an extraordinarily strong graft, without damage from autogenous harvesting of patellar tendon or hamstrings. While some data suggest higher re-rupture risk with donor tissue, this is counterbalanced by avoiding secondary surgical site damage. Technique Description: The ruptured ACL is removed and the intercondylar notch is cleaned to visualize the anatomical ACL insertion site. Using the 3-tunnel technique a gaff is passed through the intercondylar notch, through a puncture hole (incision 1) and a rear entry guide hooked to its tip. The guide point is pulled into the knee and placed in posterior aspect of the anatomic footprint of the native ACL. Through incision 2, a guide pin is drilled to this point and overdrilled with a 10-mm drill. The edges of the hole in the intercodylar notch are smoothed with a currette. The tibial footprint is cleared, a tibial aiming guide placed. Through incision 3, a guide pin is placed and over drilled with a 10-mm drill followed by a Gore-Tex reamer to ensure no impingement would inhibit graft passage. The proximal bone of a quadriceps tendon graft is sized through a 10-mm sizer and compacted. Two holes are drilled to hold sutures for the proximal aspect of the femoral graft. The quadriceps tendon graft is sized to fit through a 9-mm tunnel and the free end whipped with a stitch before being passed from outside-in through the smoothed tunnels. The femoral bone block is tapped to have a press fit initially and then is fixed with a Milagro screw. The knee is cycled ten times to remove slack and the interference fit guide pin is placed on the anterior aspect of the graft, and fixed with the knee at 15° to 30° of flexion. Stability is tested with confirmation of no impingement, and then an extra-articular reconstruction with a semitendinosus allograft is performed. The extra articular reconstruction is placed at the point between Gerdy's tubercle and the fibular head, passed under the skin and the iliotibial band, and then inserted just anterior and superior to the ACL femoral drill hole. Results: Patient outcomes in our initial experience are comparable to our autogenous bone-tendon-bone (BTB) procedures without anterior knee pain. Return to sport is similar with autogenous procedures, with a delay of 6 to 12 months. In addition, there is a possibility for acceleration of healing with the addition of platelet-rich plasma and hyaluronic acid between 1 and 3 months postsurgery. We have insufficient data so far to determine if the re-rupture rate will decline compared with reported outcomes. Conclusion: The 3-incision technique with allograft quadriceps tendon for ACL reconstruction is a reproducible surgical technique that avoids harvest from the patient's own body. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Comparison of Two Techniques for Proximal Margin Analysis of Toe Amputations: A Retrospective Review

Toe amputations are a common podiatric procedure for treatment of osteomyelitis. Whether or not the surgeon obtains a surgical cure, thus resolving the infection, can be difficult to assess. Obtaining a proximal bone margin can assist the treatment team in deciding the duration of postoperative antibiotics, need for reoperation, and postoperative care. The two senior surgeons use different methods to analyze proximal bone margins. The first surgeon obtains a microbiologic culture from the remaining bone, either at the proximal phalanx or metatarsal head, following the removal of the toe to be reviewed for osteomyelitis. Per the second surgeon's technique, the pathologist only analyzes the proximal aspect of the amputated toe for presence of osteomyelitis. Our goal is to analyze the reoperation and reamputation rates between the techniques in which the proximal margin specimens are obtained. A retrospective chart review was performed on all isolated toe or partial toe amputations from March 2017 to September 2022. There were 115 patients who met inclusion criteria. Reoperation and reamputation rates were analyzed for positive and negative infection margins from intraoperative cultures. Our study found an overall 28% reoperation rate and 26% reamputation rate for the negative margins group. In the positive proximal margin group, there was an overall 48% reoperation rate and 44% reamputation rate. Our analysis did not find a statistically significant difference between the reamputation rate in the negative margins group and the reamputation rate in the positive margins group. In conclusion, our study found that a positive proximal margin for osteomyelitis exhibited a nearly double reoperation and reamputation rate compared to patients with a negative margin, and that one margin analysis technique was not inferior to the other in regards to the need for additional surgeries.

Microsurgical Techniques for Digital Nerve Injuries and Vascular Injuries.

Tension-free end-to-end digital nerve repair or reconstruction under loupe or microscope magnification are surgical treatment options for lacerated digital nerves in patients with multiple injured digits, injuries to the border digits, or injuries to the thumb, with the goal of improved or restored sensation and a decreased risk of painful traumatic neuroma formation. Different techniques for primary repair have been described and include epineurial sutures, nerve "glues" including fibrin-based gels1,2, biologic or synthetic absorbable or nonabsorbable nerve wraps or conduits, or a combination of these materials. Nerve "glues" have demonstrated decreased initial gapping at the repair site3 and an increased tensile load to failure when utilized with a nerve wrap or conduit4,5. When there is a gap or defect in the nerve and primary repair is not feasible, nerve allograft and autograft provide similar results and are both better options than conduit reconstruction6. Concomitant or isolated digital vascular injuries may also be surgically treated with end-to-end repair in a dysvascular digit, with the goal of digit and function preservation. In the absence of complete circumferential injury or complete amputation, redundant or collateral flow may be present. Single digital artery injuries often do not need to be repaired because of the collateral flow from the other digital artery. Digital nerve and vascular injuries are often found in the context of traumatic wounds. In such cases, surgical exploration is often required, with possible surgical extension of the wounds to facilitate identification of the neurovascular bundles. The proximal and distal ends of the transected nerve and/or artery are identified, and the traumatized ends are incised sharply, maintaining as much length as possible to facilitate end-to-end repair, interposition of a graft, and the use of a conduit. The proximal and distal aspects of the nerve and/or artery are appropriately mobilized by dissecting or releasing any scar tissue or soft tissue that may be tethering the structure. The defect is measured in the natural resting position of the digit. Gentle flexion of the digit may be performed to facilitate a primary repair in the setting of very small defects. Primary repair or reconstruction is selected, and an 8-0 or 9-0 nonabsorbable monofilament suture is utilized to anastomose the appropriate structures under magnification with use of a single or double stitch6. A tubular nerve conduit is placed prior to epineurial suturing, or a nerve conduit wrap is applied circumferentially around the repair site and augmented with a fibrin glue. The wound is then irrigated and closed in a standard fashion, as determined by the presence of any soft-tissue or structural injury. Alternatives to primary repair include the use of conduits or autologous or allogenic grafting. Factors that necessitate reconstruction include gapping and poor soft-tissue integrity, which can be related to the mechanism of injury. Alternatives to repair or reconstruction include treatment of the-soft tissue or structural injury without concomitant repair or reconstruction of the damaged digital nerves or vessels. Primary end-to-end repair and reconstruction of digital nerves increases a patient's likelihood of sensation recovery, and arterial repair can preserve a digit and avoid the need for amputation. Sensation in the digits is very important for fine motor skills and interaction with the environment, and it is particularly important for patients who rely on their hands for work and/or recreation. For these reasons, the digital nerves to the border digits, such as the ulnar aspect of the small finger, radial aspect of the index finger, and both digital nerves to the thumb, are given particular attention. Surgical intervention to repair or reconstruct the digital nerves increases the likelihood of recovering pre-injury sensation; however, the chance of complete recovery remains low. A systematic review of the outcomes of digital nerve repair in adults published in 2019 showed that the average percentage of patients who had undergone repair and reported a recovery to Highet grade 4 was 24% (range, 6% to 60%)8. The rate of adverse events was comparable between the operatively and nonoperatively treated patients, with complications including neuromas, hyperesthesia, and infection. The use of a microvascular background material can provide better visualization of the proximal and distal ends while performing the repair.It is important to sharply guillotine the ends of the nerve to freshen up the laceration and provide healthy nerve ends for repair.Repair sutures need to be passed through the epineurium, with care taken not to pass through the nerve fascicles. OR = operating roomPIP = proximal interphalangealPT = prothrombin timePTT = partial thromboplastin time.

Position of the Proximal Manica Flexoria under different grades of fetlock joint extension - A biomechanical observational study in the equine fore- and hindlimb.

The aim of this study was to examine the position of the proximal manica flexoria and the proximal scutum under different grades of fetlock joint extension and to describe measurements and compare findings between equine fore- and hindlimbs. It was an observational study. During fetlock joint extension, the proximal manica flexoria and the proximal scutum displace distally relative to the palmar/plantar extent of the sagittal ridge of the cannon bone. The proximal manica flexoria is further displaced distal to the proximal scutum within the fetlock canal. No significant differences were identified between fore- and hindlimbs at different levels of fetlock joint extension. The proximal scutum was observed to be longer and thicker and the tendinous part of the manica flexoria was longer in forelimbs compared with hindlimbs. The described findings contribute to the understanding of the pathogenesis of manica flexoria tearing. The fact that the proximal scutum and the tendinous part of the manica flexoria are shorter in the hindlimb might explain why the manica flexoria is more likely to get caught on the proximal aspect of the scutum and develop a tear in the equine hindlimb.